#LeadingVBHC – We talked to Kevin Bozic, MD from UT Austin after his presentation, The Bundle Payment Health Care Environment, Recent, Current, Future.
Breanna Cunningham: Hi there. Bre Cunningham here with the Dr. Bozic, the godfather of value and outcomes in orthopedics. Dr. Bozic, thank you for taking the time. Really thoroughly enjoyed your presentation earlier.
One thing I would really like to dive into right now is patient-reported outcomes and outcome data on both the micro and kind of a macro level. The first question I have for you is on a micro level. How do you incorporate patient-reported outcome data in your day-to-day practice with treating your patients?
Dr. Kevin Bozic: Great question. As an orthopedic surgeon, the conditions that I treat generally affect people’s functional status, pain, and quality of life. I learned early on in my practice that in order to be effective and improve at what I was doing, I needed to measure the outcomes and manage my patients.
Fortunately, in orthopedics, we have about 50 years of experience with patient-reported outcomes in a research setting. But what I realized over the last 15 years in incorporating into clinical practice, the research context has really limited us in people’s understanding of how this information is used in clinical practice.
When people think that it’s primarily a research tool, it’s viewed as something secondary that’s not really critical to patient care. All of my patients who come in to see me have their PHQ2, so we assess their emotional health as well as their physical health using some measure depending on the condition that they’re coming into see.
I use that information to have a shared decision-making conversation with my patient about where they are in their stress and coping strategies and where they are in their physical health and what that means in terms of which type of treatment strategy would be most effective for them.
A patient with the same amount of arthritis by X-ray could have a lot or a little pain and could have a very well compensated coping strategy or very poorly compensated coping strategy. So there were four different scenarios there that would help me in that discussion with my patient. Before I had that information, it was very hard for me to interpret just from looking at the X-ray and talking to the patient which treatment path we would follow.
Cunningham: You mentioned something that I thought was very novel and I haven’t heard much about it until your presentation, which was that you have a specialist in your practice that really almost is a track or a pathway for patients that have a low resiliency or coping score as you have mentioned. Can you talk a little bit more about that and two things specifically. One, how you implemented it, and is it something that just you are doing or your practice is doing? And secondly, what’s the cycle? When do those patients come back to you and how is that process going?
Bozic: Great. When we started using PHQ2, we started figuring out in certain people had anxiety, depression, or difficult coping strategies that was impacting their physical health. Initially, we would diagnose that, or not diagnose it, but identify that and not know what to do with it.
What I’ve learned from my colleague, David Ring and others that have joined our practice since is that having a strategy for talking to the patient and helping them understand how their emotional health impacts their physical health and what we can do to help them with that creates a much more satisfied patient and a better outcome, so how do we do that?
We’ve tried three different models. The first model was have a behavioral health person down the hall in an office somewhere and if we identify a problem say, “Would you mind going seeing this person?” That doesn’t work very well because patients don’t want to be told, “Oh, it’s all in your head. You’re depressed, your crazy, and that’s why we can’t fix your knee.”
So what we’ve learned is number one, we’ve done communication skills training for all of the members of our team to be able to identify these types of behavioral traits that might lead to a poor outcome and then start that discussion with the patient right away in the office whether it’s the medical assistant, a physician assistant, the physician, the radiology technician and really become a more empathetic listener.
In doing so, I’ve found that a lot of patients say, “Yeah, you know what? It’s not really my knee,” or “Actually, it’s probably not the best time for me to do surgery anyway.” And some of those patients say, “and actually, is there someone that can help me with some of these other issues in my life?” And we put together a team of people, including social worker, behavioral health, case management and others that can do that. And so in a value-based painted world and a value-based delivery world that kind of model is, I think, essential.
Cunningham: Wow. So then did you meet any resistance when you were pitching or presenting this model? It seems to be on the cutting edge and really pushing the bar when it comes to value-based medicine. Do you feel like this is something that’s replicable across other practices or does it just have this unique area that allows you to kind of be more on the cutting edge.
Bozic: That’s a good question. I’ve been in traditional academic medical centers my entire career and what I’ve learned was there were some very good things about that in terms of being around highly motivated, skilled people, but what we didn’t have was the motivation for change. Those places are very successful in the current model and to try to change a big institution with fixed assets that they need to serve was very difficult.
So we had a group of people that came from those environments to Austin to really try to rethink … I wouldn’t call it rethink everything, but one of the most important things that we do is, we are an environment with a community of providers that has multiple different practice settings, most of them in private practice, some of them in a multi-specialty group or hospital employee model, but our measure of success is rather these models can be exported to all of those different practice types.
We don’t think that a typical academic practice model where we have a bunch of physicians employed by a large academic medical center is replicable around the country and so we’re really trying to find … And that’s really how, you mentioned earlier, the California Joint Replacement Registry, that’s how that … The impetus for that registry was how do we get these tools to measure patient-reported outcomes in the hands of practicing physicians in a variety of different practice settings in an inexpensive, efficient manner that doesn’t disrupt their workflow and allows them to utilize that information in their practice.
Cunningham: More on the California Joint Registry. I think that you were really influential in saying not just level one and two take that, right? But we really need that level three patient-reporting outcome data and California did an epic, I think I don’t know of a registry that’s done a better job of implementing that throughout the state. Since then they have merged with American Joint Replacement Registry and where you sit on the board. I would love to hear how that outcome data is being utilized and where you see it going in the future and maybe what we can do to improve and have better utilization of all the data that exists out there.
Bozic: Yeah. Great question. I think there is far more big data available than we know how to use or currently use in any meaningful way to improve value and so as we talked about earlier, patient-reported outcomes to me are the most important data point for us as orthopedic surgeons.
What we learned in California was if you were correcting this information outside the encounter with the physician or not using it in the encounter with the physician, it was very very difficult to get the physicians and the patients on board. The places that were most accessible under the California registry, in other words had the highest compliance with measurement of patient-reported outcomes, were places where the practitioner sat down with the patient and said, “I see based on what you’ve told me here that you have this type of physical problem and this type of coping skills problem, how can we use that to better your health?”
Just like I do with the X-ray, point to the X-ray and point to things. I do the same with the patient-reported outcomes. I’m amazed at how many patients say to me, “Where did you get that information?” And I say, “I got it from you. This is the stupid survey you filled out in the waiting area that you were mad at me about.” And so what we’ve learned is that you need to incorporate it into practice in order for it to be successful and now that the American Joint Replacement Registry has taken over, we are looking, again, at how to do that in a variety of different settings.
It’s definitely not a one size fits all approach, but with the CJR, the Comprehensive Care for Joint Replacement Initiative, we’ve been surprised at the number of community practices in different practice settings that are now interested in and actively collecting patient-reported outcomes. So, with the American Registry we’ve learned we have to be nimble and flexible and be able to use different tools in different practice settings.
What works at an academic medical center is not going to be work in a small or solo practice, and that by aggregating information, and using that as benchmarks, is one of the big advantages of the American Joint Replacement Registry. We can give people a little bit of guidance about societal norms and norms for particular conditions like hip and knee arthritis.
We still have a long way to go, but I think the technology is getting better and I think the interest in understanding of why this information is important in treating musculoskeletal disease has come a long way.
Cunningham: Final question I have for you, related to patient-reported outcomes is, if you have a practice out there whether your large or small, academic or private what would you aspire or set as a goal for a pre-op patient-reported outcome capture rate and then also a post-surgical patient-reported outcome rate. What have you seen as achievable, sustainable goals?
Bozic: That’s interesting because if you would have asked me that question two years ago I would say, “Oh, well if you can do better than 50% that’s pretty good.” What I’ve learned in the last few years is, I can’t, because of the way I use that information in my practice. It’s like waiting for the X-ray. I can’t see the patient until I have the X-ray and the PRO score, so now it’s 100% of my practice, which means, I think the relevant question is how much of that information can you gather before the visit and how much of it can you gather remotely. But if I’m seeing a patient, I have now the opportunity to say, “Let’s gather that information and then I’ll go in the room.”
It does, in some cases, change the workflow and now the patients know, “Oh, I need to get the X-ray and get that survey filled out. Maybe I should get there a few minutes early” or “I know that I’m gonna need to do this anyway. Maybe I’ll do it ahead of time.”
It’s changed, but I would say that the practices that we’re using it for, let’s see how we can do and let’s see if we really beat the bushes can we get patients to fill this out, but not really using for decision making. I think the best thing you can hope for is 50% and that’s with a lot of FT support and a lot of flogging patients and providers, but again, once you start using it and incorporating into practice, I see no reason why it can’t be 95 to 100%.
Cunningham: Sure. I love that. That’s great. It just becomes part of your day-to-day, as essential as an X-ray.
Cunningham: Dr. Bozic, it’s been an absolute pleasure. Thank you so much for spending the extra time.
Bozic: Thank you.